Vt. first in line for single payer?

Most governors are, at best, slogging their way through the world of health reform implementation. Vermont’s Gov. Peter Shumlin is hurtling through it.

Vermont is the only state to have set itself on a path to a single-payer health care system, using the national health care law as a jumping-off point.

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Shumlin can’t get there by 2014. He may not get there by 2017, when states get more flexibility under the health law to design their own health care systems. He may not get there at all.

But he believes that even small states must aim big.

“It’s a mistake for our public policymakers to think we can nibble around the broken system,” he told POLITICO in an interview at the Democratic National Convention in Charlotte, N.C. He says he wants change and believes that it’s actually easier to bring big change to little states, which he sees as less beholden than larger states and national politics are to special interests.

The rest of the United States has no interest in single payer, of course, not now nor in the near future. Not only did the 2010 health law reject single payer or a public option, its rules and structures prevent a state like Vermont from going single payer, at least at the outset.

But Shumlin’s ready to go — and he doesn’t want the health care law to stand in his way.

“This Vermont boy wants to implement that single-payer health care system tomorrow, and I don’t know why you guys want to stop me from doing that,” Shumlin said at a recent POLITICO health policy panel. “It’s the right thing to do. The rest of the world has figured it out. Let’s grow up and join them.”

The Vermont Legislature and his administration are working on setting up a state health insurance exchange under the health care law. It isn’t single-payer, although it’s often described that way. It’s an exchange. But Vermont is designing its exchange in a way that could be a platform for a state-based single-payer system.

Shumlin argues that his vision is as pragmatic as it is progressive. The efficiencies of a one-payer system will slow health care spending, freeing up dollars for jobs and economic growth, he says.

But a lot of things have to fall into place. To get to single-payer, even by 2017, Shumlin acknowledged that he would need an unprecedented slew of exemptions, tweaks or workarounds from numerous federal health programs and laws — including waivers from Medicare, Medicaid and the Affordable Care Act itself. He has to figure out what to do about big businesses that operate in Vermont and other states whose health plans are regulated not by the state, but by a federal law known as ERISA.

And the Legislature has to agree on a way of paying for it — one that won’t stir so much opposition in the business community that the whole thing falls apart.